Repair of Coarctation of the Aorta in Neonates and Infants: A Thirty-Year Experience

Between January 1962 and December 1991, 179 children less than 1 year of age underwent repair of coarctation of the aorta. Group I (1962 to 1971) consisted of 19 patients, group 11 (1972 to 1981) of 57 patients, group III (1982 to 1991) of 103 patients. Neonates (0 days old) made up 60% of group I, 57% of group II, and 70% of group III. The proportion of infants with associated complex cardiac abnormalities was 7% in group I, 25% in group II, and 39% in group III. Techniques of repair included resection with end-to-end anastomosis (n = 65), subclavian flap repair (n = 85), patch aortoplasty (n = 18), and other procedures (n = 11). The early mortality (<30 days) was lowest in group III (group I, 21%; group II, 21%; and group III, 7%; p < 0.05), but the late mortality was similar in all groups (group I, 11%; group II, 13%; and group III, 15%). The overall actuarial survival was 57.7% ± 0.15% at 27.1 years in group I, 65.7% ± 0.07% at 19.7 years in group II, and 77.5% ± 0.04% at 9.3 years in group III (p = not significant). Twenty-five restenoses requiring intervention occurred in 23 patients, for an overall restenosis rate of 16.4%. The incidence of restenosis was 23% for the patients who underwent end-to-end anastomosis, 11% for those who underwent subclavian flap repair (p < 0.1), and 27% for those who underwent patch aortoplasty (p < 0.01). Balloon angioplasty was successful in relieving 11 of the 12 restenoses in groups II and III. The mean interval (± the standard deviation) between repair of coarctation of the aorta and definitive intracardiac repair decreased from 61.5 ± 43.5 months in group I to 41.8 ± 45.5 months in group II and 10.3 ± 13.7 months in group III (p < 0.001). Twenty-eight variables (various patient characteristics, presenting signs and symptoms, management and operative variables, and severity of disease) were subjected to a Cox proportional hazards multivariate regression analysis to determine predictors of restenosis and mortality. Only patch aortoplasty was significantly associated with restenosis (p < 0.01). Increasing age at operation and the use of monofilament nonabsorbable suture were significantly associated with freedom from restenosis (p < 0.02). Younger age at operation, the need for concomitant pulmonary artery banding, and the existence of associated cardiac abnormalities were significantly associated with early mortality (p < 0.01). This retrospective review revealed that (1) subclavian flap aortoplasty is associated with the lowest rate of restenosis after repair of coarctation during infancy, and, conversely, patch aortoplasty is significantly associated with restenosis; (2) the restenosis rate is significantly lower in association with the use of monofilament nonabsorbable suture than with the use of other suture material; (3) the early mortality after coarctation repair has decreased significantly in the current era, despite a higher proportion of infants with complex cardiac malformations; and (4) late mortality is associated with younger age at operation and the presence of severe associated cardiac anomalies, and this has remained constant during the three decades covered by this study.